Medicaid Guidelines and Performance Measurements for Prenatal Care Coordination
I. Prenatal Care Coordination Administration
I.A. Develop a plan which addresses the hiring and
ongoing support and training of staff who can provide quality services that are family-centered and culturally appropriate.
I.B. Develop and implement an outreach plan to
inform potentially eligible pregnant women about the availability of PNCC services. At a minimum, the plan must:
• Identify the provider’s target population (for
example, teens only, all eligible recipients in the county, recipients in specific ZIP codes).
• Outline the strategies that will be used to
inform eligible recipients, the local community, social service providers, schools, local health care providers, and other appropriate agencies and organizations about the availability of PNCC services.
Outreach efforts could also include community presentations, informational brochures, posters, billboards, television ads, or newspaper articles.
I.C. Establish written procedures to ensure that
care coordinators include recipients, to the full extent of their ability, in all decisions regarding appropriate services and providers.
I.D. Develop and implement internal policies and
procedures for ensuring that quality services are provided in accordance with Medicaid rules. At a minimum, these policies and procedures address:
• Patient confidentiality. These policies must
include clear statements regarding the type of information that can be released, the time period for which the authorization is valid, and the agencies or individuals to whom the information can be released.
Appendix 7 (Continued)
Appendix
GUIDELINE PERFORMANCE MEASUREMENT
The provider must:
I.A. The provider’s plan to hire, support, and train
staff to provide services that are family-centered and culturally appropriate must be documented and available for review.
Documentation of staff training includes the name of the employee, date of training, and the employee’s signature.
I.B. The provider is required to have an outreach
plan available for review. The plan also must be specific to the target population and address strategies to inform eligible pregnant women about PNCC services.
I.C. Written procedures that meet the stated
guidelines are available for review.
I.D. Written policies and procedures that meet the
stated guidelines are available for review.
Documentation of all activities that meet the stated guidelines is also available for review. Provider records indicate paraprofessional supervision every 30 days, at a minimum.
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GUIDELINE PERFORMANCE MEASUREMENT
(I.D. Cont.)
(Continued)
Appendix
• Accuracy, legibility, and completeness of
records (for example, the accurate scoring of Pregnancy Questionnaires, the legibility of care plans and other written information, and documentation of all contacts with, or on behalf of, a recipient).
• Procedures to ensure that priorities established
in individual care plans are addressed in a timely manner.
• Procedures to ensure that recipients are
offered services that are sufficient in intensity. The procedures must include well-defined criteria for increasing or decreasing the intensity of services.
• Procedures to ensure that timely and
appropriate referrals are made and there is follow up on all referrals. Unless otherwise stated, follow up on referrals must be made within two weeks of the referral.
• Ongoing staff training and support, including
adequate supervision and support of paraprofessionals. Provide face-to-face supervision of paraprofessionals every 30 days, at a minimum.
• Appropriate staff-to-client ratio. Ensure that
care coordinators have an adequate amount of time to spend with each recipient. The number of clients per care coordinator will vary
depending on the needs of the recipients on their caseload.
• The provision of services by culturally
competent staff.
• The provision of services that are family
centered.
• Procedures to ensure that staff are following
the provider’s policies and procedures for the provision of services.
The policies and procedures must clearly identify:
• The staff responsible for oversight of the policies
and procedures.
• Steps for prioritizing, monitoring, and correcting
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40
Wisconsin Medicaid and BadgerCare ! May 2001GUIDELINE PERFORMANCE MEASUREMENT
I.E. Establish written procedures to ensure that a
qualified professional reviews and signs all assessments completed by paraprofessional staff.
I.F. Develop a written plan for providing timely,
non-disruptive, translator services for recipients who are hearing impaired and for recipients who do not speak or understand English.
If the provider does not have an interpreter on staff, the provider must maintain a current list of interpreters who are “on call” to provide interpreter services.
Do not use family members as interpreters when administering Pregnancy Questionnaires or for the initial care plan development. Do not use children as interpreters.
I.G. Develop written procedures for scheduling
recipients for the initial assessment, initial care plan development, ongoing care coordination and monitoring services, and health and nutrition education, if
appropriate. The schedule should allow adequate time with each individual to address her problems, develop a plan of action, and provide adequate education. If possible, schedule the initial assessment within 10 working days after the request for a service by a pregnant woman, or after receiving a referral. The procedures must also include guidelines for staff regarding the time frame within which the initial contact must be scheduled after the Pregnancy Questionnaire and care plan are completed.
I.H. Develop written procedures for following up
with recipients who fail to keep appointments (care coordination, social service, prenatal or other appointments). Include time frames within which the recipient must be contacted and the steps designed to help the recipient keep future appointments.
I.I. Maintain a current list of appropriate
community resources (for referral purposes). The list includes, but is not limited to, the following services and agencies:
• Adoption.
• AIDS/HIV.
I.E. The provider has written procedures requiring
the review by and signature of qualified professionals of all Pregnancy Questionnaires completed by
paraprofessionals.
I.F. The provider has a written plan that meets the
stated guidelines available for review. If the interpreter is not a staff member, the provider has a current list of “on call” interpreters available for review.
I.G. Written procedures that clearly outline the
provider’s plans for scheduling the initial assessment, the initial care plan development, and ongoing care coordination and monitoring services must be available for review.
I.H. Written procedures that meet the stated
guidelines are available for review.
I.I. A current list of appropriate community
resources - including, but not limited to, the services and agencies stated in the guidelines - and addresses, telephone numbers, and any associated costs is on file. Appendix 7
(Continued)
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GUIDELINE PERFORMANCE MEASUREMENT
(I.I. Cont.)
(Continued)
• Adult protective services.
• Alcohol, tobacco, and other drug abuse.
• Child welfare services.
• Children with special health care needs
program.
• Day care centers.
• Domestic/family violence.
• Early childhood intervention programs (for
example, Head Start, Birth to 3).
• Education.
• Employment/job training.
• Family planning.
• Food pantries/other food services.
• Special Supplemental Food Program for
Women, Infants, and Children (WIC) programs.
• Housing and shelters for the homeless.
• Legal assistance.
• Social services (e.g., family/marriage
counseling, family support services, clothing for newborns).
• Parenting education (including fathers).
• Perinatal loss/grief counseling.
• Respite/family resource centers.
• Transportation.
The list(s) must include the description of services offered, name of agency, address, telephone number, contact person, and any costs associated with the services.
I.J. Establish working relationships (for the purpose
of referrals) with key community agencies, social services providers, HMOs, and Medicaid primary care providers. If possible, develop written agreements that address the specific procedures to be followed for making referrals and for obtaining information on the outcome of the referrals from these agencies and providers. Ensure that staff are aware of these agreements.
Medicaid HMOs are required to sign a Memorandum of Understanding (MOU) with all PNCC providers in their service area.
I.J. The provider’s file includes written agreements
or documentation that show that the provider has made good faith efforts to develop effective working
relationships with key health and social services
providers. The provider has on file a current MOU with each HMO in the county.
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for current policy
42
Wisconsin Medicaid and BadgerCare ! May 2001I.K. Establish written procedures regarding the
release of recipient-specific information. Recipients may sign a general release of information. However, providers must obtain specific approval to release sensitive information about the recipient.
I.K. The provider has written policies regarding the
release of recipient-specific information. The policies specifically address the release of sensitive information. Appendix 7
(Continued)
GUIDELINE PERFORMANCE MEASUREMENT